Reproduction of modified Blumgart pancreaticojejunostomy in a robotic environment: a simple clipless technique

Task division by multiple console surgeons is beneficial for safe robotic pancreaticoduodenectomy implementation and education

BACKGROUND

The optimal approach for the safe implementation and education of robotic pancreaticoduodenectomy (RPD) remains unclear. Prolonged operation time may cause surgeon fatigue and result in perioperative complications. To solve this issue, our department adopted task division by the console surgeon turnover between resection and reconstruction in 2022.

METHODS

This study retrospectively investigated consecutive patients who underwent RPD from November 2009 (initial introduction of RPD) to December 2023. The analysis excluded patients who underwent concomitant resection of other organs. The cases performed by a single console surgeon (single approach) were compared with those performed by two or more console surgeons (multiple approach).

RESULTS

This study analyzed 85 consecutive RPD cases, including 51 with the single approach and 34 with the multiple approach. The operation time was significantly shorter (832 vs. 618 min, p < 0.001), and the postoperative major complication was less frequent (45% vs. 12%, p = 0.003) in the multiple approach group, although less experienced surgeons performed the multiple approach (number of RPD experiences: 19 cases vs. 5 cases, p < 0.001). The console surgeon turnover between the resection and reconstruction resulted in a safe pancreatojejunostomy performed by the less experienced surgeon (number of pancreatic reconstruction experiences: 6.5 vs. 14 cases, p = 0.010). Surgeons who started RPD with a multiple approach observed a reduction in surgical time and a lower incidence of complications earlier than those who started with a single approach.

CONCLUSION

Task division during the early introduction phase of RPD using the multiple approach demonstrated potential contributions to improved surgical outcomes and enhanced educational benefits.

Scope transition and early arterial inflow control provide safe and comfortable dissection in robotic distal pancreatectomy

PURPOSE

We describe details and outcomes of a novel technique for optimizing the surgical field during robotic distal pancreatectomy (RDP) for distal pancreatic lesions, which has become common with potential advantages over laparoscopic surgery.

METHODS

For suprapancreatic lymph node dissection and splenic artery ligation, we used the basic center position with a scope through the midline port. During manipulation of the perisplenic area, the left position was used by moving the scope to the left medial side. The left lateral position is optionally used by moving the scope to the left lateral port when scope access to the perisplenic area is difficult. In addition, early splenic artery clipping and short gastric artery dissection for inflow block were performed to minimize bleeding around the spleen. We evaluated retrospectively the surgical outcomes of our method using a scoring system that allocated one point for blood inflow control and one point for optimizing the surgical view in the left position.

RESULTS

We analyzed 34 patients who underwent RDP or R-radical antegrade modular pancreatosplenectomy (RAMPS). The left position was applied in 14 patients, and the left lateral position was applied in 6. Based on the scoring system, only the 0-point group (n = 8) had four bleeding cases (50%) with splenic injury or blood pooling; the other 1-point or 2-point groups (n = 13, respectively) had no bleeding cases (p = 0.0046).

CONCLUSION

Optimization of the surgical field using scope transition and inflow control ensured safe dissection during RDP.

[Robotic Pancreatoduodenectomy: Variations of Modified Blumgarts Pancreatojejunostomy]

Die wichtigste Komplikation nach Pankreatoduodenektomie ist die klinisch relevante Pankreasfistel. Um die Rate an Komplikationen zu senken, ist eine routinierte und standardisierte Operationstechnik zur Anlage der Pankreatojejunostomie notwendig.

Die Pankreatoduodenektomie ist im multimodalen Setting der Goldstandard zur Behandlung des lokal begrenzten Pankreaskopfkarzinoms und weiterer Pathologien. Das robotische Verfahren bietet als innovatives minimalinvasives Verfahren Vorteile bez. Morbidität und Ergonomie.

Nach der Resektionsphase folgt die Rekonstruktion beginnend mit der Pankreatojejunostomie. Die aktuell meistverbreitete robotische Technik ist die Anastomose nach Blumgart: Dabei wird eine äußere Naht transpankreatisch zwischen Jejunalwand und dem gesamten Pankreasparenchym in ventrodorsaler Ausrichtung angelegt, die Spannungs- und Scherkräfte verteilt. Die innere Naht wird durch eine Duct-to-Mucosa-Naht des Pankreasganges mit einer kleinen Jejujunostomie erreicht. In diesem Manuskript werden verschiedene Varianten dieser Rekonstruktion in robotischer Technik gezeigt.

Hinsichtlich der wissenschaftlichen Evidenz zeigt keine Anastomosenvariante einen Vorteil. Das Outcome ist abhängig von der Expertise des Operateurs, entsprechend sollte diejenige Anastomosentechnik angewendet werden, für die am meisten Erfahrung verfügbar ist. Die in diesem Beitrag gezeigten Variationen sollen für Anwender den Fokus auf wichtige Details legen sowie Tipps und Tricks zur Durchführung geben.

Introduction of robotic pancreatoduodenectomy following phase 2a IDEAL guidelines

BACKGROUND

Robotic pancreatoduodenectomy (RPD) is a newly introduced procedure, which is still evolving and lacks standardization. An objective assessment is essential to investigate the feasibility of RPD. The current study aimed to assess our initial ten cases of RPD based on IDEAL (Idea, Development, Exploration, Assessment, and Long-term study) guidelines.

METHODS

This was a prospective phase 2a study following the IDEAL framework. Ten consecutive cases of RPD performed by two surgeons with expertise in open procedures at a single center were assigned to the study. With objective evaluation, each case was classified into four grades according to the achievements of the procedures. Errors observed in the previous case were used to inform the procedure in the next case. The surgical outcomes of the ten cases were reviewed.

RESULTS

The median total operation time was 634 min (interquartile range [IQR], 594-668) with a median resection time of 363 min (IQR, 323-428) and reconstruction time of 123 min (IQR, 107-131). The achievement of the whole procedure was graded as A, "successful", in two patients. In two patients, reconstruction was performed with a mini-laparotomy due to extensive pneumoperitoneum, probably caused by insertion of a liver retractor from the xyphoid. Major postoperative complications occurred in two patients. One patient, in whom the jejunal limb was elevated through the Treitz ligament, had a bowel obstruction and needed to undergo re-laparotomy.

CONCLUSIONS

RPD is feasible when performed by surgeons experienced in open procedures. Specific considerations are needed to safely introduce RPD.

[Anastomotic techniques in minimally invasive hepatobiliopancreatic surgery]

The established anastomotic techniques conventionally used in open surgery are increasingly being implemented in a minimally invasive approach and further developed. The aim of all innovations is to carry out a safe anastomosis with a feasible minimally invasive technique; however, there is currently no broad consensus about the role of laparoscopic and robotic surgery in performing pancreatic anastomotic techniques. Pancreatic fistulas determine the morbidity following a minimally invasive resection. The simultaneous minimally invasive resection and reconstruction of pancreatic processes and vascular structures is currently exclusively performed in specialized centers.

Jejunum Patch Technique During Robot-Assisted Central Pancreatectomy: A Lesson from Open Procedure Experience

BACKGROUND

Central pancreatectomy (CP) has been established as the most common type of parenchyma-sparing pancreatectomy;1 however, CP is associated with higher morbidity and a higher pancreatic fistula (PF) rate than distal pancreatectomy or pancreaticoduodenectomy.2,3 The jejunum patch technique (JPT) for distal pancreatectomy has recently been applied, which efficiently decreases the incidence of PF.4 We have adapted this technique to CP as well as distal pancreatectomy with celiac axis resection.5 Here, we retrospectively evaluated the usefulness of JPT for open CP cases, and report the experience of robot-assisted CP using the JPT.

METHODS

Among 37 consecutive cases who underwent CP at our institution between 2011 and 2022, clinical characteristics and postoperative short-term outcomes were compared between patients who underwent CP with and without the JPT. In robot-assisted CP using the JPT, after resection of the middle of the pancreas the transected jejunum was elevated through the retrocolic route in a Roux-en-Y fashion. The pancreatic stump was covered by the JPT using a modified Blumgart technique, following pancreaticojejunostomy for the distal side.6 RESULTS: Among the entire cohort, 19 patients underwent CP using the JPT. The clinically relevant PF rate of the JPT group was significantly lower (47.4%) than the no-JPT group (83.3%, p = 0.022), and the length of drainage and hospital stay were shorter in the JPT group (p= 0.010 and p = 0.017, respectively). The blood loss of robot-assisted CP using the JPT was 20 mL, and the JPT took only 15 min.

CONCLUSION

Robot-assisted CP using the JPT is an easy-to-use and promising procedure, based on experience and outcomes from open surgery.

Professor Leslie H. Blumgart-Pioneering Hepatopancreaticobiliary Surgeon: a Tribute

Leslie Harold Blumgart was the surgeon behind making Hepatopancreaticobiliary surgery a speciality and his recent demise will always leave a void in that field. He was the person who classified anatomical variations in the biliary tract and devised a special anastomotic technique to decrease the rate of postoperative pancreatic duct fistula after Whipple's pancreaticoduodenectomy. His contribution in managing hepatobiliary oncology cases with chemotherapy and radiotherapy was also significant. No wonder, he was designated as the "living legend" by the International Hepatopancreaticobiliary Association.